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Witness borne

It was a rare permutation of words for a third year medical student to hear. After glancing behind me to make sure she wasn’t addressing someone else, I waited for the rest of her request.

* * *

We had just left the room of one of our patients. She had stomach pain. A complete workup had been unrevealing. The endoscopy showed uninflamed gastric mucosa, the barium swallow and CT scan showed no masses or strictures, the gastric emptying study showed regular movement of stomach contents, and blood tests indicated no infection.

With no tangible source for her pain, her illness had morphed from “acute” to “chronic.” It had components that were “psychosomatic” rather than “organic.” These labels were code for a change in game plan. It was likely the start of a long battle against pain with elusive origins. But it would be fought in the outpatient setting and not the hospital.

We implicitly understood this. However, to our 25-year-old patient, nothing really had changed. She was still in pain, and we had muted but not fixed it. How could she go home?

The resident had a reputation for being persuasive. Explaining the test results was the easy part. Explaining what to do next would take verbal finesse.

“Look,” she said, and the patient looked up from her iPhone. “You’re sitting in the dark in the middle of the day. This can’t be good for you, right?”

She drew open the shades, letting the afternoon sun spill into the bed. The young woman didn’t blink.

“All I can think about is my pain,” she said.

“Of course,” said the resident. “There’s nothing else to do here but focus on it. When was the last time you got out of bed?”

“Yesterday,” said the patient. “Then I felt nauseous.”

“How about you try again today?” The resident kept her voice light, cheery.

“I’m going to get nauseous again.”

“That’s what the medications are for. They helped before, didn’t they?”

Silence.

“Getting out of bed will also help the pain.”

The young woman slowly shook her head.

I watched the resident’s back slightly stiffen. “You don’t want to be in the hospital if you don’t need to be here. You could get sicker. It’s dangerous.”

“How can I go home if I’m in pain?”

How do you tell someone that more time spent with us won’t resolve her pain?

“Don’t you think you would feel better in your own home?”

The patient bit her lip and issued what to a hospitalist is the ultimate threat. “If you send me out, I’m going to come back.”

* * *

In medicine we talk about “bearing witness” to the suffering of our patients. We treat with a pill or scalpel, and we also care by listening, by empathizing, and by giving patients our emotional energy.

But I’m learning that witnessing is a two-way mirror.

The slight creep of exasperation into the attending’s voice when the patient asks a question best answered by a social worker? The fidgeting by the medical student at the very back of the room during an intern’s long presentation? How we listen to complaints, how we field questions, how we explain our plans, how we interact with staff?

How we try to explain to a young woman that she must leave the hospital without an answer?

Patients bear witness to our actions too.

* * *

We left the room, and the resident let out a long breath and grit her teeth. There was another reason, she was convinced, the young woman was so reluctant to leave.

For all our talk of privacy, there is an elephant in each hospital room. Each patient is saddled with a roommate–a stranger who knows the intimate details of her medical story. The thin curtain between beds does nothing to block voices explaining test results and plans of care.

In this case, the stranger was another young woman with almost identical symptoms. Ms. M was a new patient on our service, and she had listened intently to the entire conversation.

“Did you hear what Ms. M said to her family as we left?” the resident asked me, in a tone filled with righteous indignation. I shook my head.

“‘See, they’re kicking her out. Just like they want to do with me.’”

The resident puffed out her cheeks. “They’re feeding off each other. And now neither one is ever going to leave.”

She thought a moment. “I need you.”

My job was simple: Split the patients up. Ms. M needed a walk, and she needed it at a very specific time. I was to circle the hospital floors with her while the resident spoke to her roommate about leaving.

* * *

I wasn’t a stranger to situations in which roommates witnessed the team’s reactions to each of them. In the past, the discomfort stemmed from the patients’ differences rather than their similarities.

The most jarring juxtaposition I remembered came with two previous patients, both middle-aged, on our medicine service months before.

When an otherwise healthy 45-year-old develops severe pneumonia with fluid buildup around the lungs, a doctor’s internal alarms go off. This type of pneumonia may signal something more sinister. It can accompany a compromised immune system, or a structural abnormality that makes it easier for an infection to enter, or with a mass that blocks part of the lung.

The woman and her husband were very quiet as we told them about the suspicious spots we saw on the CT scan of her lungs. When a biopsy confirmed lung cancer, they didn’t ask many questions and instead clasped each other’s hands as she cried.

They rarely moved or spoke much when we entered the room each morning. We told them the next steps for the day, and they would nod. Before leaving, the attending would pat her hand, which was surrounded by balled up tissues.

Probably because it was emotionally easier, each morning we stepped past her bed by the door and visited her roommate first.

The roommate was antsy to leave, but her slightly elevated potassium was taking its time to get back to a normal level.

“So what will it be, doctor-doctor?” she asked our attending, an MD-PhD. “More kayexelate today?” As a nurse manager, she wasn’t intimidated by the white coats who surrounded her bedside and seemed particularly amused by those of us wearing the shorter ones. With not much else to do other than wait for her electrolytes to rebalance, she bantered with the team.

Every time I laughed, I felt a flash of guilt about the woman an arm’s length away on the other side of the curtain. I’m sure I wasn’t the only one who wondered how she felt hearing our laughter.

Then I pictured her expressionless gaze as the attending told her about chemotherapy, about surgery, about what her new life could look like.

Maybe she didn’t hear it at all.

* * *

“I’m getting tired,” said Ms. M as we slowly padded around the hospital floor. “Can I go back to bed?”

“Let’s sit down a minute,” I said, eyeing the closed door to her room and feeling like a bumbling accomplice in a B-movie.

One minute turned into several. I was stalling, but I was also curious. Who was this woman besides a hospital roommate, besides someone with intractable abdominal pain?

She worked as a nurse’s assistant. She was in danger of losing her job because she took so many sick days. She had a son. She was two years sober. She was scared.

Out of the corner of my eye, I saw the resident leave the room and flash me a thumbs-up.

As I helped Ms. M climb back into her bed, she grabbed my arm. “Thank you for listening,” she said, her dark brown eyes looking directly into my own.

I felt that familiar flash of guilt as I wondered whether she had noticed my own wandering gaze and attention.

* * *

Walking with Ms. M hadn’t been the first time my gaze wandered. The first time was much worse.

The code stroke had been called during the last five minutes of my shift. Coat in hand, I followed the resident to the coronary care unit.

The 50-year-old man was answering questions strangely, a nurse said. He had seemed fine after his coronary bypass surgery, but now, several hours out, there was something off about his grammar and syntax.

The resident shined a penlight into his eyes. Pupils reactive, she reported with relief.

But his answers to her questions were fluent nonsense. Real words were arranged into an order devoid of meaning. He kept trying, unaware that he was a textbook example of Wernicke’s aphasia.

Then he projectile vomited blood.

Four of us grabbed his bed and ran out of the coronary care unit, through the hallways, down the elevator, and to a CT scanner.

One of his hands clutched his head while he grimaced in pain. The other hung on to the tray in front of him while he continued to vomit into it.

We stared at the screen as we waited for the image of his brain to appear.

It’s not often you hear four people gasp at the exact same time, but that’s what we did as we watched an enormous splotch of white appear that covered about half of the left hemisphere.

It’s strange to associate a color with a potential death sentence. On a head CT, white is blood. When it spills out of vessels or tissues, it irritates surrounding structures. One structure is the superior temporal gyrus, which when damaged renders a patient unable to speak coherently or understand others.

When there is enough blood, it increases the pressure inside the skull so much that structures in the brain become compressed. With nowhere else to go, they push against bone, which is perceived as immense pain.

The brainstem, at the bottom, bears the brunt. If the area postrema compresses, the patient feels nauseous and vomits. As the areas controlling heart rate, blood pressure, and arousal get damaged, the patient slowly loses consciousness and goes into shock. If the pressure isn’t brought down by medications or surgery, the patient will never wake up.

The man continued to moan in pain as we brought him back to the coronary care unit, pushed hydralazine, and paged neurosurgery. The resident shined a penlight into his eyes again. That his pupils now no longer contracted when light hit them was a surprise to no one.

Though I continued to understand none of what he was saying, he interspersed one word consistently among the rest: “hurts.”

He was confused, and his eyes were wide with fear. He looked at all of us, witnessing our own fear and concern. The second-year resident, somewhat pale, returned his gaze.

“This is … a little bit serious,” she said to him. I’ll never forget those words, her pause, the enormity of her understatement. They were the last words spoken directly to him.

As he slowly lost consciousness, he never stopped looking at us. I couldn’t stop thinking that my face could be one of the last he would see. I couldn’t stand that thought. And I couldn’t meet his gaze.

The anesthesiologists ran into the room for emergent intubation as he closed his eyes. I finally stepped back and stood against the wall, giving them space as they wheeled him away to the operating room.

It struck me how much courage it takes to tell a dying person he’s dying and continue to look him in the eye. This resident had only a few years more experience than I did. It struck me how much more I had to learn.

The resident turned away from the spot where his bed used to be, with tears in her eyes.

* * *

The next morning I entered Ms. M’s room and approached her bed. The shades were open, and the bed on the other side of the curtain was empty.

With some apprehension, I roused her for the requisite line of questioning. I remembered her roommate’s resistance to answering questions and reluctance to look up from her phone.

I’m not sure what she saw in my face. Maybe it was surprise that two women who were the same age, shared a hospital room, and presented with such similar symptoms could have different reactions. Maybe it was relief that I wouldn’t have to partake in any more roommate ruses. But I’d like to think it was happiness untinged by an ulterior motive.

She sat up. “Can we go for a walk again later?”

Note: Certain details of this story were altered to protect patient privacy.

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Shara Yurkiewicz is a first year resident at Overlook Medical Center in New Jersey. She is training to be a doctor in physical medicine and rehabilitation (PM&R). Her residency is broken into two chapters: Year one in internal medicine at Overlook Medical Center, followed by years two through four at Stanford for PM&R. She received her MD from Harvard and her BS from Yale. She was an AAAS Mass Media Fellow, and has written for the LA Times, Discover, and MedPage Today.
Follow her on Twitter: @sharayurkiewicz